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Difficulty: MediumReduction of Risk Potential

Following shift report on a medical-surgical unit, which client condition demands the nurse's immediate evaluation?

  1. A client who underwent a thoracentesis 1 hour ago and demonstrates asymmetric chest wall expansion with a heart rate of 118 bpmAnswer
  2. B
    A client with chronic obstructive pulmonary disease whose arterial blood gas results show a pH of 7.36, PaCO2PaCO_2 of 55 mmHg, and HCO3−HCO_3^- of 32 mEq/L
  3. C
    A client who is 3 hours post-lumbar puncture, sitting upright in a chair, and reporting a severe throbbing headache
  4. D
    A client receiving a continuous heparin infusion for a deep vein thrombosis who is urgently requesting assistance to use the restroom

Answer

The client who underwent a thoracentesis and demonstrates asymmetric chest wall expansion and tachycardia.
The client who recently had a thoracentesis is presenting with asymmetric chest wall expansion and tachycardia, which are hallmark signs of a pneumothorax. This is a life-threatening procedural complication that compromises airway and breathing, requiring immediate medical intervention.

Step-by-Step Solution

1
Evaluate the clinical status of the client who had a thoracentesis.
Asymmetric chest wall expansion and a heart rate of 118 bpm strongly suggest a pneumothorax, a critical complication of the procedure.
Airway and breathing emergencies must always be prioritized according to the ABCs of nursing.
2
Analyze the arterial blood gas values for the client with chronic obstructive pulmonary disease.
The pH is normal (7.36), while PaCO2PaCO_2 and HCO3−HCO_3^- are elevated, indicating a fully compensated state.
This is an expected baseline finding for chronic respiratory disease and does not require emergency intervention.
3
Assess the situation of the client who is post-lumbar puncture.
The client is experiencing a typical spinal headache exacerbated by an incorrect upright position.
Although the position needs to be corrected to supine to reduce risk of further cerebrospinal fluid leakage, the condition is not immediately life-threatening.
4
Consider the client with deep vein thrombosis receiving heparin.
The client needs prompt assistance to ambulate safely and prevent injury.
This is an important safety measure but takes lower priority compared to acute physiological decompensation.

Key Concept

Prioritization of Care and Recognition of Post-Procedure Complications
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Topics

Reduction of Risk Potential

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